This questionnaire is designed for adults and the scoring system isn't appropriate
for children. Scores in women will run higher, as seven
symptoms/conditions apply exclusively to women, while only 2 apply exclusively to
men.

In SECTION A it lists factors in your medical history which promote the growth of
Candida alibicans. SECTIONS B and C deal with
symptoms commonly found in individuals with a yeast-connected illness.

Please answer every question in each section. Then move on to each section and submit
only if all questions have been answered.

Completing this questionnaire and receiveing
your results should help you and your health professional evaluate the possible role of Candida in
contributing to your health problem. Yet it will not provide an automatic "Yes" or
"No" answer.

SECTION A: HISTORY

Have you taken tetracyclines or other antibiotics for acne for 2 months or longer?

YES
NO

Have you, at any time in your life, taken other "broad spectrum" antibiotics* for
repiratory, urinary or other infections? This means for 2 months or longer, or as in
shorter courses of 4 or more times in a 1 year period. (*Includes: Keflex, Ampicillin, Amoxicillian, Ceclor, bactrim and Septra)

YES
NO

Have you, at any time in your life, been troubled by persistent vaginal problems or had 3
or more episodes of vaginitis in a year?

YES
NO

Have you ever been pregnant?

No
Once
More

Have you taken birth control pills?

No
6-24 months
More than 2 yrs.

Have you taken prednisone, Decadron (R) or other cortisone-type drugs?

No
2 weeks or less
2 weeks or more

Does exposure to perfumes, insecticides, fabric shop oders and other
chemicals provoke symptoms?

None
Mild
Moderate/Severe

Are your symptoms worse on damp, muggy days or in moldy places?

YES
NO

Have you had persistent athlete's foot, "jock itch" or other chronic fungous
infections of the skin or nails? Have such infections been persistent or moderate?

None
Mild
Severe

Do you crave sugar?

YES
NO

Do you crave breads?

YES
NO

Do you crave alcoholic beverages?

YES
NO

Does tobacco smoke REALLY bother you?

YES
NO

SECTION B: MAJOR SYMPTOMS

For each symptom which follows, choose "mild" if the symptom
occurs occasionally, "moderate" if the symptom occurs
frequently, and "severe" if the symptom is persistent
and/or disabling.

Fatigue or Lethargy

None
Mild
Moderate
Severe

Feeling of being "drained"

None
Mild
Moderate
Severe

Poor Memory

None
Mild
Moderate
Severe

Feeling "spacey" or "unreal"

None
Mild
Moderate
Severe

Depression

None
Mild
Moderate
Severe

Numbness, burning or tingling

None
Mild
Moderate
Severe

Muscle aches

None
Mild
Moderate
Severe

Muscle weakness or paralysis

None
Mild
Moderate
Severe

Pain and or swelling joints

None
Mild
Moderate
Severe

Abdominal pain

None
Mild
Moderate
Severe

Constipation

None
Mild
Moderate
Severe

Diarrhea

None
Mild
Moderate
Severe

Bloating

None
Mild
Moderate
Severe

Troublesome vaginal discharge

None
Mild
Moderate
Severe

Persistent vaginal burning or itching

None
Mild
Moderate
Severe

Prostatitis

None
Mild
Moderate
Severe

Impotence

None
Mild
Moderate
Severe

Loss of sexual feelings

None
Mild
Moderate
Severe

Endometriosis

None
Mild
Moderate
Severe

Dysmenorrhea

None
Mild
Moderate
Severe

Premenstrual tension

None
Mild
Moderate
Severe

Spots in front of eyes

None
Mild
Moderate
Severe

Erratic vision

None
Mild
Moderate
Severe

SECTION C: OTHER SYMPTOMS

While the symptoms in this section occur commonly in patients with yeast-connected illness,
it should be noted that they also occur in individuals who do not have Candida. For each symptom which follows, choose "mild"
if the symptom occurs occasionally, "moderate" if the
symptom occurs frequently, and "severe" if the symptom
is persistent and/or disabling.